Improving Care Coordination for Children with Mental Health Conditions

Jan 2, 2015, 9:00 AM

Nicole M. Brown, MD, MPH, MHS, is a general pediatrician at Montefiore Medical Center and an assistant professor of pediatrics in the Division of General Pediatrics at Albert Einstein College of Medicine at Yeshiva University in New York City. She is alumna of the Robert Wood Johnson Foundation (RWJF)Clinical Scholars program.

Many patients have left an impression on my heart since I began my journey as a pediatrician, but one I cared for early in my career sticks with me. He was a wiry 8-year-old boy exhibiting symptoms of an anxiety and conduct disorder: He was very aggressive, had acted inappropriately with his younger sister, smeared feces around the house, and was difficult to manage. He had been severely and physically abused, and although child protective services had gotten involved, he had fallen out of the system after the case was “closed” and stopped showing up for therapy.

By the time his grandmother brought him to see me, I was the first doctor to see him in about two years. In the hour that I spent with him that day, it became clear that his treatment—or lack thereof—was inextricably bound up in his family’s various other challenges. His family lived in poverty, and faced food insecurity issues, in addition to a long, cyclical history of abuse and child protective services involvement. His grandmother was shuttling between various social service agencies, doing her best to complete forms and meet the requirements for public assistance. Yet despite her best efforts, she wasn’t really able to manage it all and, as a result, the boy’s health care was falling through the cracks.

We happened to have a mental health professional in the clinic, so during that initial visit, he and I conferred and agreed on a mental health diagnosis, then set about helping the boy get the therapy he needed. We also assisted his grandmother with navigating the various service agencies the family depended on.

If I hadn’t had access to a psychiatrist or psychologist in the clinic, things may have gone very differently. As pediatricians, we do not always feel well equipped to diagnose or manage severe mental health conditions, and so we rely on our colleagues in psychology and psychiatry to help diagnose and develop treatment plans in collaboration with the family. However, in more resource-poor settings where access to a co-located mental health professional is not always a reality, we often make referrals to a mental health professional, subjecting the child and family to another appointment and, given the shortage of child psychiatrists and psychologists, often a lengthy wait for an initial appointment. In the end, my young patient and his grandmother may not have made it to the appointment, and his problems would almost certainly have cascaded.

The cascade might also have involved physical symptoms. Anxiety often triggers asthma or other conditions, and the root cause can be easy to miss. Even if it’s properly diagnosed, treating it requires coordination among health care professionals.

Unfortunately, this patient’s circumstances aren’t all that unique. His story has been repeated a number of times among other patients and families that I have encountered and, collectively, they have inspired me to understand the common themes around trauma, mental health issues, poor social support, and fragmented service delivery that run through their shared experiences.

Working with colleagues in the Robert Wood Johnson Foundation Clinical Scholars Program, I began to take a closer look at these themes, analyzing data from the 2007 National Survey of Children’s Health to get a better understanding of the frequency and circumstances of unmet need for care coordination among children with mental health problems. In our sample of just over 7,500 children who experienced mental health issues that included anxiety, depression, and conduct disorder, we found that 43 percent had a need for care coordination, but among the parents who reported that their children needed such coordination, 41 percent described the need as unmet.

Digging a little deeper, we also found that the highest risk of unmet need for care coordination was associated with child anxiety disorder, parenting stress, lower income, and public or no insurance. By contrast, parents reporting that they had social support or received family-centered health care had a lower risk of an unmet need for care coordination.

That’s important information for clinicians, of course. But it’s also useful for policymakers as they consider how to allocate resources for “health homes” that state Medicaid programs and health care providers can establish with Affordable Care Act funding. Health homes are intended to provide a cost-effective model of interdisciplinary collaboration and care coordination for patients with chronic physical and mental health conditions.

While our study sheds light on where coordination is most needed and most lacking, it also underscores the need for more training for physicians to help us recognize and diagnose anxiety and other mental health conditions earlier, and to enhance our ability to ensure that they can access appropriate and effective mental health services.

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